CWW - Confined Space Entry Permit

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a CSE Competent Person.

1. IDENTIFICATION

• Date and Time of Entry

  Date

• Entry/Access Permit Number

• Confined Space Location

• Description of Works

• Manhole No

• Site Photo

  Media

2. PERSONNEL

• Enter the names of Entry Personnel and Expiry Date of CSE Ticket

• Enter the names of Surface Personnel and Expiry Date of CSE Ticket

• Relevant Emergency contact numbers are accessible on site ?

  Yes

  No

  N/A

3.ISOLATION

• Electrical Isolation Required

  Yes

  No

  N/A

• Mechanical Isolation Required

  Yes

  No

  N/A

• Contact with System Operator Required

  Yes

  No

  N/A

• Required Isolation in Place - Checked by

• Signiture

  Sign

4. ATMOSPHERIC TESTING

• Gas Detector Calibration Date

  Date

• Recommended Levels

• Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

• Record Peak Test Readings Prior To Entry

• Oxygen (%)

• Explosive Gas (LEL%)

• Hydrogen Sulphide (ppm)

• Carbon Monoxide (ppm)

• Other Gases Tested

• Record any

5. VENTILATION

• Natural

  Yes

  No

  N/A

• Forced

  Yes

  No

  N/A

• Wash Down

  Yes

  No

  N/A

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE

• Select any of the following that will be taken into consideration before entry into the Confined Space

• Weather

  Safe

  At Risk

  N/A

• Traffic

  Safe

  At Risk

  N/A

• Noise

  Safe

  At Risk

  N/A

• Catchment

  Safe

  At Risk

  N/A

• Flow Volume

  Safe

  At Risk

  N/A

• Trade Waste Discharge

  Safe

  At Risk

  N/A

• Industrial/Commercial Discharge

  Safe

  At Risk

  N/A

• Domestic Discharge

  Safe

  At Risk

  N/A

7. PERSONAL PROTECTION EQUIPMENT

• Select relevant PPE to be worn or carried by persons entering the Confined Space.

• First Aid Kit

  Yes

  No

  N/A

• Helmet, Boots, Safety Vest

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Overalls, Chemical Suite

  Yes

  No

  N/A

• Waders

  Yes

  No

  N/A

• 2 Way Radio

  Yes

  No

  N/A

• Gas Detector

  Yes

  No

  N/A

• Self Rescue Respirator

  Yes

  No

  N/A

• Fall Arrest Device

  Yes

  No

  N/A

• Lifeline

  Yes

  No

  N/A

• Harness

  Yes

  No

  N/A

• Airline

  Yes

  No

  N/A

• Road Signage

  Yes

  No

  N/A

• Platforms

  Yes

  No

  N/A

• Barricades

  Yes

  No

  N/A

• Lighting

  Yes

  No

  N/A

• Bosun

  Yes

  No

  N/A

• Ladders

  Yes

  No

  N/A

• Man Cage

  Yes

  No

  N/A

• Fire Extinguisher

  Yes

  No

  N/A

8. HOT WORK

• Has the area been cleared of combustible materials for 15m ?

  Yes

  No

  N/A

• Have all drains within 15m been covered with a wet fireproof blanket ?

  Yes

  No

  N/A

• Will hot work be performed in the Confined Space ?

  Yes

  No

  N/A

• Are appropriate fire extinguishes on site ?<br>List the type of Extinguishers .

  Yes

  No

  N/A

• Is a water hose available & tested on site ?<br>If no, list precautions taken to substitute a water hose.

  Yes

  No

  N/A

• Is extra ventilation required ?<br>If "YES" what type and where will it be located.

  Yes

  No

  N/A

• All power leads clear of pipelines ?

  Yes

  No

  N/A

• All power leads clear of access way ?

  Yes

  No

  N/A

• Will the Hot works release toxic vapours ?<br>If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.

  Yes

  No

  N/A

8.1. Welders

• Are welding machines/gas bottles at least 8m from the manhole/pit entry ?

  Yes

  No

  N/A

• Are electric welders earthed ?

  Yes

  No

  N/A

• Are welders serviced to manufacturers specifications ?

  Yes

  No

  N/A

• Welders Name & Signature

  Sign

8.2. Authority to perform "HOT WORKS" works

• I have checked the above conditions and consider it safe to carry out this work.

• Name & Signiture

  Sign

• Select date

  Date

9. CITY WEST WATER ENTRY

• CONTACT CITY WEST WATER FOR ENTRY TIME - 9313 8499

• Time phoned IN (Entry)

  Date

• Time of intended EXIT

  Date

• CWW Operator Name

10. APPROVAL TO ENTER

• The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.

• Name and Signature

  Sign

• Select date

  Date

11. JOB COMPLETION

• All persons have left the Confined Space. No further Entries Permitted without New Permit

• Name and Signature

  Sign

• Select date

  Date

12. CITY WEST WATER EXIT

• CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499

• Time of EXIT

  Date

• CWW Operator Name